NYC 9/11 Public Portal Document
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ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM
WESTCHESTER COUNTY LABORATORIES AND RESEARCH
2 Dana Road, Valhalla, New York 10595
H
(914) 593-5575 NYS-ELAPNo. 10108 —
Time/Date Set:_________ Form A-70 (rev, 1/96)
Sample Type (circle one):
J
02. Non-Potable
3. Non-Potable Treated
4. Other_____________
Bottle
Chain of Custody? .yes no
Time/Date Collected:. -------- Comments:
Collected By: aA .A <Zt9i I Agency Code: PWS #:_________ Source ID: Type Descriptor:
Collected From: Bill to:
Location’s/lndividual’s Name Name/Company
Street______________________ Street__________
City/SVZip__________________ City/St/Zip
Identification of Source Phone#: __Fax #:,
Collection I CA, CH, Bl? Check#: Amounts,
BACTERIOLOGICAL ANALYSES ORGANIC POTABLE ANALYSES ORGANIC NONPOTABLE/SOLID ANALYSES
Lab#:______________________ Lab #:____________ -‘A / ~ /
(circle tests) (circle tests) / / j
1. Heterotrophic Plate J. J Trihalomethanes (524) t 1. Purgeable Halocarbons (624/8260)
Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260)
2. Coliform P/A (public supplies) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624)
3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (606/8060)
4. Fecal Coliform (all samples) 5. Microextractables (504) • 5. Organochlorine Pesticides (608/8080)
5. Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8080)
6. Macroscopic 7. Pesticides/PCB screen (508) 7. Herbicides (SM-18/6640; 8151)
7. API '' - 8. PCB as Decachlorobiphenyl (5b8A) 8. ' Other Pesticides.(SM-18/6630)
8. Other:___________________ 9. Herbicides (515) 9. Petroleum Hydrocarbon Scan (310-13)
10. Pesticides (525) ,10. Glycols in Water
Refrigerated? ,yes. no 11. Carbamate Pesticides (531) 11. Acid Extractables (625/8270)
12. Glyphosate (547) 1i&Base Neutral Extractables (625/8270)
Chlorinated?: .yes. .no 13. Diquat (549) ^^GC/MS Unknown Scan .
14. Chlorination Disinfection Byproducts (551) 14. Purgeable Halocarbons (DEF)
Free Chlorine Res:- mg/L 15. Haloacetic Acids (552) < ,15. Purgeable Aromatics (DEF)
16. Other Pesticides (SM-18/6630) ■■ 16. Pesticides (DEF)?
Total Chlorine Res: -Htg/L 17. Petroleum/Hydrocarbon Scan (31.0-13) . 17. PCB’s (Arochlors) (DEF)
pH,
INORGANIC ANALYSES REQUESTED - Lab#:
(circle tests)
1. Color 20. Acidity ’391Aluminum 59 Potassium
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2. Turbidity 21. Alkalinity, as CaCOa 40. intimony /€o?Belenium
3. pH 22. Bromide 41. irsenic |6l/siiver
4. Conductivity 23. Bromate/Chlorate/Chlorite 42. larium ez Sodium
5. Corrosivity (temp: .’C) 24. Chloride 43> teryllium Thallium
6. BOD (5 day) 25. Cyanide 44. Boron W' Vanadium
7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65?'Zinc__________
8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOa 46. Calcium, as CaCOa CtP
9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca*^ 66. Metals/CN
10. Dissolved Oxygen 29. Nitrogen, Nitrate as N .48',Chromium, Total 67. Volatiles
Ji. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-volatiles
12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N /ta Cobalt 69. Pesticides/PCB's
13. Solids, Percent (%) 32. Oil and Grease / SlJCopper 70. Disk Deliverables
! 52.|lron
14. Solids, Settleable 33. Phenol ISLE
15. Solids, Suspended 34. Phosphorus. Total as P \^Lead 71. TCLP-Metals
16. Solids. Total 35. Phosphorus. Ortho as P ^^.Magnesium 72. TCLP-Pesticides
17. Solids. Total Dissolved 36. Sulfates /Ss.lManganese 73. TCLP-Herbicides
18. Solids. Total Volatile 37. Surfactants / 56.^ercury' 74. TCLP-Volatiles
® Other: A. 38. IIV254 I 57.jMolybdenum 75. TCLP-BNA's
Xss/Nickel
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NYC-WTC_000070898
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